Search

Die Luxation des Fibulakopfchens ohne Begleitverletzungen ist selten und tritt infolge eines Traumas auf. Eine genaue Unfallanamnese und eine klinische Untersuchung mit akkurater Inspektion des Kniegelenks sind essenziell fur das Erkennen dieses seltenen Verletzungsmusters. Es sollten immer Rontgenbilder im Seitenvergleich sowie bei unklarem Befund eine Computertomographie (CT) durchgefuhrt werden. Die Therapiemoglichkeiten umfassen eine geschlossene Reposition und, bei Versagen dieser, eine offene Reposition mit temporarer Arthrodese, wie sie in diesem Fall erfolgt ist.

Hintergrund Eine gangige Meinung ist, dass eine akute Rekonstruktion des vorderen Kreuzbandes (VKB) mit einem erhohten Arthrofibroserisiko einhergeht. Dies beruht jedoch haufig auf Arbeiten aus den 1990er-Jahren mit Nachbehandlungskonzepten, welche mit der aktuellen Therapie nicht mehr vereinbar sind.

Eine postoperative Gelenkinfektion nach dem Ersatz des vorderen Kreuzbands (VKB) ist eine schwerwiegende Komplikation dieses Eingriffs. Die lokale Behandlung des Transplantats mit Vancomycin wahrend und nach der Sehnenpraparation erscheint hilfreich, um die Infektionsrate nach VKB-Ersatz zu senken. Bei der Methode, welche die Autoren seit August 2012 in ihre Operationsroutine integriert haben, werden 500 mg Vancomycin (die kleinste Applikationsmenge) in 100 ml steriler Ringerlosung aufgelost (Konzentration: 5 mg/ml). Nach Praparation des Transplantats auf dem Seitentisch wird es mit Fixationsmaterial mit einer Vancomycin-getrankten Kompresse ummantelt. Vor dem Einziehen in das Kniegelenk wird das Transplantat einmalig mit Ringerlosung abgespult. In einer eigenen Fallserie mit uber 1000 Patienten konnte keine postoperative Gelenkinfektion mehr beobachtet werden. Die Ergebnisse werden durch vergleichbare Fallserien in der Literatur bestatigt. Negative Effekte der Vancomycin-Behandlung wurden bislang nicht beschrieben. Ob eine Resistenzentwicklung von Bakterien durch eine breite Verwendung des Reserveantibiotikums begunstigt wird, muss abgewartet werden. Die lokale Vancomycin-Applikation wahrend und nach der Transplantatpraparation scheint das Auftreten postoperativer Gelenkinfekte beim VKB-Ersatz mit autologen Sehnen zu verhindern.

An avulsion of the posterior tibial insertion of the lateral meniscus occurs during rotational distortion of the knee and can be associated with a tear of the anterior cruciate ligament (ACL). We performed a follow-up of 28 patients who, following anatomical ACL reconstruction using the ipsilateral semitendinosus graft, underwent either transosseous repair of the posterior lateral meniscus root (n=14) or no intervention (n=14). The meniscus root tears were classified as Forkel I lesions. All patients were examined 6 months after surgery and undertook scoring using International Knee Documentation Committee Score (IKDC). Comparing the repair group with the no repair group the subjective IKDC 6 months after surgery was 75,72% (±1,019) and 75,56 (±1,058). Regarding the objective IKDC 8 × A (57,1%) and 6 × B (42,9%) could be ascertained in the repair group whereas 6 × A (42,9%), 6 × B (42,9%), and 2 × C (14,3%) scoring could be ascertained in the no repair group. It remains unclear if surgery on type Forkel I PLMRT provides benefits compared to the nonsurgical procedures as in both groups stability might occur. The purpose of this article was to report the outcome of surgical repair of lateral meniscus root tears.

To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis. A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months. In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p

Wiederherstellung von Form und Funktion eines Meniskus durch Adaptation eines basisnahen Langsrisses mit einem arthroskopischen Nahtsystem. Instabile, basisnahe Meniskuslangsrisse, vornehmlich im Hinterhorn von Innen- oder Ausenmeniskus. Dislozierte, basisnahe Korbhenkelrisse des Innen- und Ausenmeniskus. Schlechte Gewebequalitat bei zerfasertem Meniskusgewebe. Meniskusrisse in der avaskularen Zone (Zone I). Ungenugende Durchblutung der Gelenkkapsel und Meniskusbasis. Degenerative Meniskuslasionen. Vordere oder hintere Kniegelenkinstabilitat. Allergie auf nicht resorbierbares Nahtmaterial. Ventrale Arthroskopie-Standardzugange. Arthroskopische Beurteilung des Meniskusrisses mit dem Tasthaken. Anfrischen der Rissrander und Perforation der Meniskusbasis zur Induktion von Blutungen. Adaptation der Rissrander und Fixation mit einem Faden-Ankersystem uber einen gleichseitigen Standardzugang bei Rissen im Meniskushinterhorn oder uber einen kontralateralen Standardzugang bei Rissen im Meniskusseitenhorn. Vollbelastung in Streckung des Kniegelenks mit Knieorthese, schmerzadaptiert innerhalb der 1. Woche nach der Operation. Funktionelle Behandlung, unbelastet, zwischen Extension und 90° Flexion des Kniegelenks (0/0/90). Bei gleichzeitigem Ersatz des vorderen Kreuzbandes Weiterbehandlung nach den Behandlungsgrundsatzen fur den Ersatz des vorderen Kreuzbandes. Seit dem Jahr 2000 wurden Meniskusrisse bei mehr als 300 Patienten mit dem All-inside-Nahtsystem refixiert. Im Rahmen einer multizentrischen Studie der ESSKA (European Society for Sports Medicine, Surgery and Arthroscopy) wurde bei 20 Patienten das Ergebnis mit einer direkten MRT-Arthrographie (Gadolinium) beurteilt. Die Ankerplattchen stellten sich meist nicht dar, die Stichkanale gaben ein hypodenses Signal. Bei Rerupturen war der Meniskus aus der Fadenschlaufe ausgerissen. Knorpellasionen wurden nicht gefunden. Es gab keine Komplikationen durch die nicht resorbierbaren Ankerplattchen.

Die Menisken haben fur eine ungestorte Kniegelenkfunktion eine wichtige biomechanische Bedeutung und sollten bei der Behandlung von Kniegelenkverletzungen moglichst erhalten werden. Kapselnahe Langsrisse mit noch vorhandener Kollagenstruktur des Meniskus stellen die klassische Indikation zur Refixation dar. Bei gleichzeitiger Ruptur des vorderen Kreuzbands sollte dieses mit einem Ersatzkreuzband versorgt werden. Horizontal-, Radiar- und Schragrisse konnen seltenst erfolgreich refixiert werden. Daher werden sie sparsam reseziert. Besondere Bedeutung hat der Korbhenkelriss. Fur dessen korrekte Diagnose sind Anamnese, klinischer Befund sowie Magnetresonanztomographie wichtig. Neben den klassischen Nahttechniken haben inzwischen auch Meniskusanker sowie komplexe Nahtsysteme mit Faden und Implantat ihren Platz in der Meniskuschirurgie. Die Refixation mit Ankern beinhaltet gegenuber den klassischen Techniken einen erheblichen Zeitgewinn, aber auch die Gefahr von Knorpeldefekten sowie freien Gelenkkorpern. Die seit einigen Jahren erhaltlichen komplexe Nahtsysteme haben sich besonders im Hinterhornbereich, wo mit arthroskopischen Nahttechniken nur sehr schwierig Nahte platziert werden konnen, bewahrt.

The reconstruction of a ruptured anterior cruciate ligament (ACL) is a frequently performed operation, however technically demanding with a revision rate of approximately 10%. The correct placement of bone tunnels in femur and tibia is the most important variable to achieve a successful outcome. A distinct knowledge of the anatomic insertion sites is crucial. The ideal location for the femoral bone tunnel is achieved when a 1-2 mm posterior wall is left to the over-the-top position and when the entry to the bone tunnel is at 10 o'clock (right knees) or 14 o'clock (left knees) in the frontal plane. The femoral bone tunnel can be drilled through the tibial bone tunnel (transtibial technique) or through an anteromedial arthroscopic portal. According to recent studies the use of an anteromedial portal helps to reduce the risk of misplacement of the bone tunnel. The center of the tibial bone tunnel should be located on an imaginary line between medial border of the anterior horn of the lateral meniscus and the medial tibial spine. The position of the tibial guide wire has to be far enough posterior to avoid impingement of the graft with the roof of the intercondylar notch. Measures for quality control include the intraoperative use of an image intensifier (fluoroscopy), instrumented laxity measurements and a postoperative radiograph in 2 planes. The use of computer assisted surgery cannot routinely be recommended at present.

Ziel: Evaluation der Aussagekraft verschiedener CT-Vermessungsmethoden des Patellofemoralgelenkes nach arthroskopischer Stabilisierung bei Patellaluxation. Material und Methode: Axiale CT-Vermessung des Patellofemoralgelenkes bei 18 Patienten nach arthroskopischer medialer patellofemoraler Naht ohne oder mit postoperativer Rezidivluxation unter Verwendung samtlicher in der Literatur bei entspanntem M. quadriceps empfohlenen Messmethoden in 4 Knieflexionsstufen (15 °, 30 °, 45 °, 60 °). Ergebnisse: Postoperativ zeigten nur der laterale Patellofemoralwinkel bei 15 ° und 30 ° und der Kongruenzwinkel bei 15 ° Flexion signifikante Unterschiede hinsichtlich der auserhalb des Normbereichs liegenden Fallzahl zwischen den nie luxierten und den postoperativ nicht reluxierten Patellae. Beide Gruppen unterschieden sich auch hinsichtlich ihrer Mittelwerte nicht signifikant. Auser bei der Patellalateralverschiebung nivellierten sich mit zunehmender Flexion die Unterschiede zwischen Normal- und Luxationsgruppen fast vollstandig, Unterschiede zwischen Normal- und Reluxationsgruppe bei jedem Flexionsgrad zeigten nur der laterale Patellofemoralwinkel, der Patellaneigungswinkel und die Patellalateralverschiebung. Eine zunehmende Flexion (> 30 ° und besonders bei 60 °) fuhrt die meisten Messwerte zuruck in den Normbereich. Schlussfolgerungen: Bei der CT-Vermessung des Patellofemoralgelenkes nach Stabilisierungsoperation erscheinen der laterale Patellofemoralwinkel und der Kongruenzwinkel am nutzlichsten. Die Messungen sollten in mehreren Flexionsgraden durchgefuhrt werden. Purpose: To evaluate the diagnostic impact of different CT-based measurements to analyze the patellofemoral alignment after arthroscopic reconstruction in patients with patella dislocation. Materials and Methods: In 18 patients with dislocation of the patella, CT of the patellofemoral joint was performed after arthroscopic reconstruction. Various methods recommended in the literature were used to analyze the structure and the alignment of the patellofemoral joint with a relaxed quadriceps muscle. Axial CT scans were taken in four different knee flexion angles (15 °, 30 °, 45 °, 60 °). Results: After arthroscopic stabilization in patients with patella dislocation, only the lateral patellofemoral angle (15 ° and 30 ° knee flexion) and the congruence angle (15 ° knee flexion) showed significant differences between the CT-measurements in the normal and the operated group. The differences of the remaining mean values were not significant due to a high standard deviation. With increasing flexion of the knee, the differences between the normal and the dislocation group almost disappeared. Only the lateral patellofemoral angle, the patella tilt and the lateral patella shift revealed differences between the normal and the group with recurrent dislocation in every degree of knee flexion. With increasing knee flexion above 30 ° and especially at 60 °, the majority of the measured values returned to the normal range. Conclusions: For CT-measurements of the patellofemoral joint after arthroscopic stabilization, the patellofemoral angle and the congruence angle seemed to be most useful. The measurements of the patellofemoral joint should be taken in various degrees of knee flexion.

Fur den primaren Ersatz des vorderen Kreuzbandes (VKB) wurde in den letzten Jahrzehnten eine Vielzahl verschiedener Transplantate und Rekonstruktionstechniken eingesetzt. Drei verschiedene Sehnentransplantate haben sich in den letzten Jahren als primare Transplantatwahl herauskristallisiert: Patellarsehne, Hamstringsehnen und Quadrizepssehne.

In einer fast 100 jahrigen Entwicklung wurden zahllose korpereigene, korperfremde und synthetische Gewebe zum Ersatz der Kreuzbander des Kniegelenks eingesetzt. Unter den derzeit favorisierten autologen Geweben haben das zentrale Patellarsehnendrittel, eine gevierfachtes Sehnentransplantat des Pes anserinus (M. semitendinosus/M. gracilis) und ein zentrales Quadricepssehnentransplantat die groste klinische Bedeutung. Mit einigen Einschrankungen ist auch der Einsatz von Leichentransplantaten gerechtfertigt. Die einzelnen Transplantate weisen spezifische Unterschiede bezuglich der biomechanischen Eigenschaften, der Primarfixation und der Einheilung im Knochenkanal auf. In klinischen Studien konnte eine eindeutige Uberlegenheit eines der genannten Transplantate nicht verifiziert werden. Bei der Transplantatauswahl mussen die unterschiedlichen anatomischen und funktionellen Anforderungen des vorderen und des hinteren Kreuzbandes berucksichtigt werden. Bei der Versorgung komplexer Bandverletzungen und bei Revisionsfallen ist eine sorgfaltige, praoperative Planung mit ggf. modifizierter Transplantatwahl erforderlich.

Der vorliegende Bericht vermittelt die personliche Erfahrung uber das 1jahrige AGA-Pittsburgh-Fellowship, welches der Autor vom 1.4.96–31.3.97 absolvierte. Neben einer Beschreibung des Department of Orthopaedic Surgery in Pittsburgh wird im besonderen die wissenschaftliche Tatigkeit im Musculoskeletal Research Center und die klinische Tatigkeit im Center for Sports Medicine charakterisiert. Die wissenschaftlichen Projekte des Autors beinhalteten vornehmlich biomechanische Untersuchungen am hinteren und vorderen Kreuzband unter Verwendung einer Robotertechnologie. Weiterhin werden die Arbeitsweise im Labor, organisatorische Aspekte des Fellowships und die soziale Einbindung mit der Familie im Gastland beschrieben.

Radiographic enlargement of bone tunnels following anterior cruciate ligament (ACL) reconstruction has been recently introduced in the literature; however, the etiology and clinical relevance of this phenomenon remain unclear. While early reports suggested that bone tunnel enlargement is mainly the result of an immune response to allograft tissue, more recent studies imply that other biological as well as mechanical factors play a more important role. Biological factors associated with tunnel enlargement include foreign-body immune response (against allografts), non-specific inflammatory response (as in osteolysis around total joint implants), cell necrosis due to toxic products in the tunnel (ethylene oxide, metal), and heat necrosis as a response to drilling (natural course). Mechanical factors contributing to tunnel enlargement include stress deprivation of bone within the tunnel wall, graft-tunnel motion, improper tunnel placement, and aggressive rehabilitation. Graft-tunnel motion refers to longitudinal and transverse motion of the graft within the bone tunnel and can occur with various graft types and fixation techniques. Aggressive rehabilitation programmes may contribute to tunnel enlargement as the graft-bone interface is subjected to early stress before biological incorporation is complete. Further basic research is required to verify the effect of the various proposed factors on the etiology of bone tunnel enlargement. We recommend that routine follow-up examinations after ACL reconstruction should include the measurement of bone tunnel size in order to contribute to a better understanding of the incidence, time course, and clinical relevance of this phenomenon. Improved and more anatomical surgical fixation techniques may be useful for the prevention of bone tunnel enlargement.

The use of interference screws for femoral graft fixation in anterior cruciate ligament (ACL) reconstruction with hamstring grafts can result in rotation of the graft around the screw leading to changes in the final position of the graft within the bone tunnel.In a prospective study 107 patients (54 right and 53 left knees) underwent ACL reconstruction with a hamstring tendon autograft. Femoral fixation of the graft was performed with a standard right-thread screw in all cases. Patients were assessed at 6 months postoperatively with the international knee documentation committee (IKDC) standard evaluation including instrumented laxity measurements and the results were compared between right and left knees.A significantly higher postoperative anterior laxity was observed in left knees with a negative Lachman test in only 64 % of the cases compared with 87 % in the group of right knees. Accordingly, instrumented laxity measurements of the reconstructed knee compared with the contralateral knee revealed significant differences between left and right knees (left knees 1.8±1.2 mm and right knees 1.0±1.4 mm).This study demonstrates the importance of femoral graft positioning and its sensitivity to multiple influencing factors. The use of standard right-thread interference screws for femoral graft fixation in the mirrored situation of right and left knees may produce a systematic error in ACL reconstruction. Due to a possible rotation of the graft around the screw, the final position of the transplant may vary thus leading to significant changes in anterior translation of the operated knee.

The surgeon who is planning to perform posterior cruciate ligament (PCL) reconstruction has to consider several factors previous to surgery. These elements of strategy include graft selection, the use of one- or two-bundle technique, drilling of a tibial tunnel or the use a tibial inlay technique, treatment of concomitant ligament injuries, and in some cases the requirement to address varus malalignment with valgus high tibial osteotomy. If additional grafts are needed for multiligament reconstruction (e.g., posterolateral reconstruction), autografts from the contralateral side or allografts can be an alternative. When choosing a graft for PCL reconstruction, one should imagine the requirements for an ideal graft as listed in Table 1.

Die Menisken des Kniegelenkes vermindern die auf die Knorpeloberflachen von Femur und Tibia wirkenden Krafte und agieren als sekundare Gelenkstabilisatoren. Im lateralen Kompartiment werden ca. 70%, im medialen Kompartiment ca. 50% der Last uber die Menisken vermittelt. Die Hinterhorner tragen hierzu zwischen 50% in Streckung und 85% in 90°-Flexion bei [2]. Ermoglicht werden diese Funktionen durch die Form und Lage der Menisken, welche durch einen Ausgleich der knochernen Inkongruenz die Kontaktflache zwischen Femur und Tibia erhohen. Die Menisken bewegen sich bei Flexion entsprechend des Roll-Gleit-Mechanismus zum Erhalt der Kongruenz nach dorsal und folgen ebenso einer Rotationsbewegung.

Wundinfektionen bleiben trotz vieler Fortschritte in der Kontrolle von chirurgischen Infektionen von groser Bedeutung, gerade bei steigenden Zahlen von ambulanten operativen Eingriffen und insbesondere bei immunsupprimierten Patienten. Barrieremasnahmen, wie Operationsabdeckmaterial und Operationskleidung, zur Vermeidung der Kontamination von Eintrittspforten sind gut etabliert. Die optimalen Materialcharakteristika fur diese Materialien sind gut definiert. Dennoch besteht uber den Einsatz verschiedener Materialen, insbesondere die Verwendung von Einweg- vs. Mehrwegmaterialen, eine lange dauernde Kontroverse. Der Einsatz von Mehrweg- vs. Einwegmaterialien wird hier diskutiert; es konnen derzeit nach den vorliegenden Studien weder in Bezug auf Effektivitat noch Umweltvertraglichkeit Vor- oder Nachteile fur die eine oder andere Wahl klar festgestellt werden. Die Europaische Union hat kurzlich eine neue Normenreihe fur Abdeckmaterialien und Operationskleidung formuliert (EN 13795), deren Spektrum von Anforderungen an Hersteller wie auch an Prufverfahren fur die Materialeigenschaften reicht. Die Implementierung dieser Normen stellt erhebliche Anforderungen an Hersteller bzw. Wiederaufbereiter dieser Materialien und wird zu einer weiter verbesserten Materialqualitat fuhren.

Postoperative surgical site infections remain frequent despite intensive control programs. With rising numbers of operations and invasive procedures in the outpatient setting and in immunocompromised patients, the prevention of wound infections presents a rapidly growing challenge to the medical community. Barrier measures including drapes and surgical gowns to prevent wound contamination, have clearly reduced the rate of wound infections. The optimal material characteristics for operating gowns and drapes are well defined, but there is still a long running controversy on the use of single-use versus reusable materials. We review the efficacy and ecological impacts of these different approaches. Currently no superiority of any of these approaches with regard to either efficacy or ecological impact can be found. The European Union has recently published a series of mandatory standards to specify material characteristics of barrier materials used in operating theatres (EN 13795). Their scope include production standards of these materials as well as specific processes in auditing their characteristics. The implementation of these norms will clearly present a challenge to European hospitals but will lead to better material characteristics in the end.

The reconstruction of a ruptured anterior cruciate ligament (ACL) is a frequently performed operation, however technically demanding with a revision rate of approximately 10%. The correct placement of bone tunnels in femur and tibia is the most important variable to achieve a successful outcome. A distinct knowledge of the anatomic insertion sites is crucial. The ideal location for the femoral bone tunnel is achieved when a 1-2 mm posterior wall is left to the over-the-top position and when the entry to the bone tunnel is at 10 o'clock (right knees) or 14 o'clock (left knees) in the frontal plane. The femoral bone tunnel can be drilled through the tibial bone tunnel (transtibial technique) or through an anteromedial arthroscopic portal. According to recent studies the use of an anteromedial portal helps to reduce the risk of misplacement of the bone tunnel. The center of the tibial bone tunnel should be located on an imaginary line between medial border of the anterior horn of the lateral meniscus and the medial tibial spine. The position of the tibial guide wire has to be far enough posterior to avoid impingement of the graft with the roof of the intercondylar notch. Measures for quality control include the intraoperative use of an image intensifier (fluoroscopy), instrumented laxity measurements and a postoperative radiograph in 2 planes. The use of computer assisted surgery cannot routinely be recommended at present.

To evaluate the diagnostic impact of different CT-based measurements to analyze the patellofemoral alignment after arthroscopic reconstruction in patients with patella dislocation.In 18 patients with dislocation of the patella, CT of the patellofemoral joint was performed after arthroscopic reconstruction. Various methods recommended in the literature were used to analyze the structure and the alignment of the patellofemoral joint with a relaxed quadriceps muscle. Axial CT scans were taken in four different knee flexion angles (15 degrees, 30 degrees, 45 degrees, 60 degrees ).After arthroscopic stabilization in patients with patella dislocation, only the lateral patellofemoral angle (15 degrees and 30 degrees knee flexion) and the congruence angle (15 degrees knee flexion) showed significant differences between the CT-measurements in the normal and the operated group. The differences of the remaining mean values were not significant due to a high standard deviation. With increasing flexion of the knee, the differences between the normal and the dislocation group almost disappeared. Only the lateral patellofemoral angle, the patella tilt and the lateral patella shift revealed differences between the normal and the group with recurrent dislocation in every degree of knee flexion. With increasing knee flexion above 30 degrees and especially at 60 degrees, the majority of the measured values returned to the normal range.For CT-measurements of the patellofemoral joint after arthroscopic stabilization, the patellofemoral angle and the congruence angle seemed to be most useful. The measurements of the patellofemoral joint should be taken in various degrees of knee flexion.

Various graft choices have evolved over the past few decades for the primary reconstruction of the anterior cruciate ligament (ACL). Three predominant autologous graft choices exist today: patellar, hamstring, and quadriceps tendons. Clinical studies have as yet failed to demonstrate significant differences in clinical outcome among these grafts, irrespective of their varying fixation techniques. Therefore, other factors such as graft harvest morbidity have become more important when comparing different grafts. These factors can differ substantially between the grafts, depending on the type of patients' activities, the injury pattern, and the associated injuries of the knee joint. A basic knowledge of these factors and the parameters that affect the mechanical and biological behavior of the reconstructed ACL can help to find the appropriate graft choice for each individual patient. Factors such as harvest site morbidity, fixation techniques, osseous integration, and tunnel widening are discussed based on current clinical and basic science studies. Finally, an outlook is given for future alternatives with evolving techniques for tissue-engineered grafts, allografts, or the transplantation of xenogeneic donor tissue.

Suture techniques are the standard for fixation of meniscus bucket-handle lesions. In 1993 a new method for meniscus repair with self-reinforced biodegradable "arrows" was introduced. Currently, various meniscus implants are available in Germany and are widely used clinically. The purpose of this paper was to evaluate and discuss the literature on biodegradable meniscus implants. Relevant articles were retrieved from Medline of the National Library of Medicine (1966 until July 2000) using the combined search strategy for the keywords "meniscal repair" and "arrow." Ten publications were found. The reported advantages of meniscus arrows are the reduced operation time, the easy surgical technique, and the reduced risk of neurovascular injury. In most experimental studies, lower failure strength of meniscus arrows was found compared to meniscus sutures. In clinical studies, the meniscal healing rates comparing the arrow technique and suture technique are comparable. Various complications of the new arrow technique have been reported such as inflammatory foreign-body reaction, cartilage lesions, and arrow displacement. Based on the existing literature, no final judgment is possible. Currently, individual indications depending on the kind of meniscal lesion and location are recommended. A combination of suture and arrow technique might be a treatment option, but further prospective randomized studies and longer follow-ups are necessary.

Over the past century numerous graft materials have been used for the reconstruction of the cruciate ligament of the knee. Among the autologous tissues that are currently recommended as graft materials, the central bone patellar tendon bone graft, a quadrupled hamstring graft and the central quadriceps tendon graft have the greatest clinical significance. With some limitations, allograft materials can also be used. Each of the three mentioned grafts has specific features regarding morphological and structural properties, graft fixation and graft incorporation. Clinical studies have failed to identify any of the three grafts as superior to the others. When choosing the graft for surgery the different anatomy and function of the anterior and posterior cruciate ligaments have to be considered. For the treatment of multiple ligament injuries and for revision cases, thorough preoperative planning is necessary and modified graft selection may be required.

We compared the mechanical behavior of two common hamstring graft constructs that are frequently used for reconstruction of the anterior cruciate ligament-Graft A: quadrupled semitendinosus tendon fixed with titanium button/polyester tape and suture/screw post, and Graft B: a double semitendinosus and double gracilis tendon fixed with a cross pin and two screws over washers. The experimental protocol used to evaluate each graft construct included stress relaxation (with and without preconditioning), cyclic loading, and a tensile load-to-failure test. The amount of stress relaxation without preconditioning was 60.6% for Graft A and 53.8% for Graft B. With preconditioning, it significantly decreased (p0.05) to 48.7 and 42.3%, respectively. Elongation of the graft construct in response to 100 cycles of loading (20-150 N) was 1.8 and 0.6% of the original length for Grafts A and B, respectively. However, after a series of five cyclic loading tests, the residual permanent elongation for each construct was 3.8 +/- 1.2 and 0.3 +/- 0.2 mm, a significant difference (p0.05) between the two graft constructs. Further analysis found more than 90% of the permanent elongation in the proximal and distal regions of Graft A, which consisted of polyester tape tied to a titanium button (proximal) and sutures tied around a screw post (distal). The tensile load-to-failure tests also revealed significant differences (p0.05) between the two graft constructs. Linear stiffness was 32 +/- 1 and 119 +/- 19 Nmm and ultimate load was 415 +/- 36 and 658 +/- 128 N for Grafts A and B, respectively. For Graft A, the polyester tape consistently failed; for Graft B, slippage or tearing from the washers was the mode of failure. We conclude that a quadruple-hamstring graft fixed over a cross pin proximally and with metal washers distally (Graft B) has less permanent elongation in response to cyclic loading and has structural properties superior to those of a graft construct that includes suture and tape material (Graft A). The large permanent elongation following repetitive loading of a graft construct with tape and suture material during the early postoperative period is of concern.

The objectives of this study were to determine the effects of hamstrings and quadriceps muscle loads on knee kinematics and in situ forces in the posterior cruciate ligament of the knee and to evaluate how the effects of these muscle loads change with knee flexion. Nine human cadaveric knees were studied with a robotic manipulator/universal force-moment sensor testing system. The knees were subjected to an isolated hamstrings load (40 N to both the biceps and the semimembranosus), a combined hamstrings and quadriceps load (the hamstrings load and a 200-N quadriceps load), and an isolated quadriceps load of 200 N. Each load was applied with the knee at full extension and at 30, 60, 90, and 120 degrees of flexion. Without muscle loads, in situ forces in the posterior cruciate ligament were small, ranging from 6+/-5 N at 30 degrees of flexion to 15+/-3 N at 90 degrees. Under an isolated hamstrings load, the in situ force in the posterior cruciate ligament increased significantly throughout all angles of knee flexion, from 13+/-6 N at full extension to 86+/-19 N at 90 degrees. A posterior tibial translation ranging from 1.3+/-0.6 to 2.5+/-0.5 mm was also observed from full extension to 30 degrees of flexion under the hamstrings load. With a combined hamstrings and quadriceps load, tibial translation was 2.2+/-0.7 mm posteriorly at 120 degrees of flexion ut was as high as 4.6+/-1.7 mm anteriorly at 30 degrees. The in situ force in the posterior cruciate ligament decreased significantly under this loading condition compared with under an isolated hamstrings load, ranging from 6+/-7 to 58+/-13 N from 30 to 120 degrees of flexion. With an isolated quadriceps load of 200 N, the in situ forces in the posterior cruciate ligament ranged from 4+/-3 N at 60 degrees of flexion to 34+/-12 N at 120 degrees. Our findings support the notion that, compared with an isolated hamstrings load, combined hamstrings and quadriceps loads significantly reduce the in situ force in the posterior cruciate ligament. These data are in direct contrast to those for the anterior cruciate ligament. Furthermore, we have demonstrated that the effects of muscle loads depend significantly on the angle of knee flexion.

The posterolateral structures of the knee consist of a complex anatomical architecture that includes several components with both static and dynamic functions. Injuries of the posterolateral structures occur frequently in conjunction with ruptures of the posterior cruciate ligament. To investigate the role of the posterolateral structures in maintaining posterior knee stability, we measured the in situ forces in the posterolateral structures and the distribution of force within the structures' major components, i.e., the popliteus complex and the lateral collateral ligament, in response to a posterior tibial load. Eight cadaveric knees were tested. With use of a robotic/universal force-moment sensor testing system, a posterior tibial load of 110 N was applied to the knee, and the resulting five-degree-of-freedom kinematics were measured at flexion angles of 0, 30, 60, 75, and 90 degrees. The knees were tested first in the intact state and then after the posterior cruciate ligament had been resected. These tests were also performed with an additional load of 44 N applied at the aponeurosis to simulate contraction of the popliteus muscle. In the intact knee, the in situ forces in the posterolateral structures were found to decrease with increasing knee flexion. After the posterior cruciate ligament was sectioned, these forces increased significantly at all angles of flexion. With no load applied to the popliteus muscle, the in situ forces in the popliteus complex were similar to those in the lateral collateral ligament. However, with a load of 44 N applied to the popliteus muscle, in situ forces in the popliteus complex were three to five times higher than those in the lateral collateral ligament. These results reveal that in response to posterior tibial loads, the posterolateral structures play an important role at full extension in intact knees and at all angles of flexion in posterior cruciate ligament-deficient knees. The popliteus muscle appears to be a major stabilizer under this loading condition; thus, the inability to restore its function may be a cause of unsatisfactory results in reconstructive procedures of the posterolateral structures of the knee.

To investigate the effect of simulated contraction of the popliteus muscle on the in situ forces in the posterior cruciate ligament and on changes in knee kinematics, we studied 10 human cadaveric knees (donor age, 58 to 89 years) using a robotic manipulator/universal force moment sensor system. Under a 110-N posterior tibial load (simulated posterior drawer test), the kinematics of the intact knee and the in situ forces in the ligament were determined. The test was repeated with the addition of a 44-N load to the popliteus muscle. The posterior cruciate ligament was then sectioned and the knee was subjected to the same tests. The additional popliteus muscle load significantly reduced the in situ forces in the ligament by 9% to 36% at 90 degrees and 30 degrees of flexion, respectively. No significant effects on posterior tibial translation of the intact knee were found. However, in the ligament-deficient knee, posterior tibial translation was reduced by up to 36% of the translation caused by ligament transection. A coupled internal tibial rotation of 2 degrees to 4 degrees at 60 degrees to 90 degrees of knee flexion was observed in both the intact and ligament-deficient knees when the popliteus muscle load was added. Our results indicate that the popliteus muscle shares the function of the posterior cruciate ligament in resisting posterior tibial loads and can contribute to knee stability when the ligament is absent.

The goal of health services is to provide opportunities for effective care to persons who can benefit from it in a manner that is acceptable to the consumer and the provider, at a cost that is acceptable to the public at large. Health services research strives to determine whether that goal has been achieved, in whole or in part, and to identify factors that enhance or diminish the possibility of achieving that goal.

The ankle sprain is one of the most common injuries in sports. It is useful to classify the grade of injury clinically. Stress x-rays, stress ultrasound or radiographic examinations are not necessary. Based on the analysis of 24 controlled studies we conclude that functional treatment is sufficient. It does not lead to higher subjective or objective instability nor to a greater number of reinjuries. Functional treatment has no complications. Although controlled studies about the treatment of athletes are missing, but there is no reason for a different treatment in athletes.

Man unterscheidet drei verschiedene Schmerzarten im Sport: 1) Schmerzen infolge intensiver korperlicher Anstrengung (Belastungsschmerz), 2) Schmerzen bei akuten Verletzungen, 3) Schmerzen bei chronischen Verletzungen bzw. degenerativen Erkrankungen. Dem Belastungsschmerz wird eine Schutzfunktion vor Uberanstrengung zugeschrieben. Eine Therapie dieser Schmerzen ist nicht notwendig. Bei der Therapie akuter Verletzungsschmerzen stellt die Kaltetherapie in Form von Eis, Eiswasser, Eisschwammen die Methode der Wahl dar. Gelenkarthrosen oder chronische Ruk- kenschmerzen fuhren besonders bei Alterssportlern zu chronischen Schmerzen bei sportlicher Aktivitat. Bei jungen Leistungssportlern mit hoher Trainingsintensitat entstehen oft Schmerzen infolge von Uberlastungsschaden des Bewegungsapparates. Die Therapieprinzipien dieser Schmerzzustande sind uneinheitlich.